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Psychotherapy and the controlled act component of psychotherapy
The following addresses questions nurses have about the controlled act of psychotherapy and how this affects their nursing practice:
What is psychotherapy?
Psychotherapy is defined as “an intense client-therapist relationship which often involves the examination of deeply emotional experiences, destructive behaviour patterns and serious mental health issues.” (Health Professions Regulatory Advisory Council, 2006).
It includes a deep assessment of life processes that focus on behaviour modifications, thinking patterns, cognition, emotional response and social functioning.
What are the educational requirements for nurses to perform psychotherapy?
To competently practice psychotherapy, nurses need knowledge, skill and judgment. Nurses are accountable to reflect on their practice, determine their individual learning needs, developing a learning plan annually. Nurses continually reflect on their practice and determine what best helps them achieve their objectives (for example, taking refresher courses or obtaining certifications). CNO does not require nurses to obtain specific additional training or certification (e.g. courses, hours, supervision, etc.) with respect to psychotherapy. Nor does CNO approve or endorse specific continuing education programs or certifications.
It is up to the nurse and/or their employer to determine the appropriate training or requirements (certifications, degrees, etc.) necessary to safely perform psychotherapy.
What is the controlled act component of psychotherapy?
The controlled act is the component of psychotherapy considered to be the highest risk to the patient. It does not include all psychotherapy practices and is not defined by a technique.
The controlled act is defined in the Regulated Health Professions Act, 1991 (RHPA) as:
“Treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning.”
How will I determine if I’m performing the controlled act of psychotherapy?
Based on the RHPA definition, there are five elements in the controlled act. All five elements must be met for you to be performing the controlled act:
- You are treating a patient
- You are applying a psychotherapy technique
- You have a therapeutic relationship with the patient
- The patient has a serious disorder of thought, cognition, mood, emotional regulation, perception or memory
- This disorder may seriously impair the patient’s judgment, insight, behaviour, communication or social functioning
Nurses may perform elements of psychotherapy, but not the controlled act of psychotherapy. For example, if only four of the above components apply, you are not performing the controlled act.
You are in the best position to determine whether or not you are performing the controlled act according to the criteria.
The diagram below highlights that the controlled act is one element in the wide-ranging practice of counselling and psychotherapy. Many of the activities that nurses frequently engage in share some common traits with psychotherapy, but they are not psychotherapy. For example, activities such as health teaching, providing information, encouragement, support or instruction are not psychotherapy.
Do I require an order to perform the controlled act of psychotherapy?
RNs and RPNs can independently perform the controlled act of psychotherapy without an order in some practice settings. However, workplace policies or legislation governing the practice setting (For example, the Public Hospitals Act), may require nurses to obtain an order to perform the controlled act of psychotherapy. Delegation of the controlled act of psychotherapy by NPs, RNs and RPNs is prohibited.
Are nurses able to use the title “psychotherapist”?
Yes. If you choose to use the "psychotherapist" title, you must:
- When speaking to patients you may only describe yourself as a “Psychotherapist” if you also use your restricted nursing title .
For example: "I am an RN, psychotherapist." Or, "I am an NP and a psychotherapist."
- When describing yourself in writing, you must provide your full name as it appears on the College's Register (Find a Nurse), your protected title, and the title, "psychotherapist."
For example: Jane Goode, RN, Psychotherapist
I’m a nurse and I perform psychotherapy. Should I also register with the College of Registered Psychotherapists of Ontario?
This decision is up to you. As a nurse, if you have the knowledge, skill and judgment to do so, you may perform psychotherapy in your nursing practice.
If you register with the College of Registered Psychotherapists of Ontario, this must be reported to CNO.
As a nurse, can I open an independent psychotherapy practice?
Yes. Our Independent Practice guideline outlines the accountabilities of nurses who are in independent practice. As a nurse in independent practice, you should obtain legal and business advice as needed, so you can identify, understand and comply with the laws that apply to your practice (for example, laws relating to privacy, employment standards and taxation). The College does not provide legal advice. Nurses in independent practice remain accountable to all applicable CNO standards and guidelines.